The Heart’s Hidden Risks

The Heart’s Hidden Risks

Are you aware of these lesser-known factors for cardiovascular disease?

Most of us know the drill when it comes to keeping our heart healthy: Exercise, don’t smoke, eat plenty of fruit and veggies, maintain a healthy weight and watch our blood pressure and cholesterol.

Indeed those are smart habits to follow. High blood pressure, high cholesterol, smoking, diabetes, obesity and a family history of heart disease are some of the major risk factors for cardiovascular disease.

But in addition to the “big ones,” lesser known risks for heart disease abound, including certain cancer therapies, some chronic diseases and even your dental health.

Autoimmune diseases

If you have an autoimmune disease, in which your body’s immune system attacks a part of your body like your joints or skin, you may be at a greater risk of a heart attack or stroke than someone without an autoimmune condition.

People who have rheumatoid arthritis, for example, have up to double the risk of developing coronary artery disease or heart failure compared to people who don’t.

And people with psoriasis — especially younger patients with severe psoriasis — have an increased risk of having a heart attack.

The chronic inflammation in autoimmune diseases may trigger a continuous immune response that can affect the arteries, explains Daniel Sauri, MD, a cardiologist with AMITA Health.

Plaque that clogs arteries in the heart is “like a cholesterol glob on the wall of the heart covered by a thin membrane,” he says. Inflammation can cause the membrane to rupture, resulting in blood clots that cause heart attacks or strokes.

Rheumatoid arthritis can also cause infiltrative cardiac disease, in which proteins are deposited in the heart, affecting the heart’s ability to pump effectively, says Douglas Chapman, MD, associate professor of cardiology at Loyola Medicine. The heart heart gets stiff, and the valves can begin to leak.

The good news is that physicians are well aware of the link between autoimmune diseases and cardiovascular disease, and they closely monitor the heart health of their patients, Chapman says.

If you have an autoimmune disease like rheumatoid arthritis, psoriasis or lupus, you can keep your heart strong by exercising regularly and eating a healthy diet. “Those lifestyle changes are complementary [to treatment] and very helpful,” Sauri says.

Chemotherapy and radiation

Some chemotherapy drugs — especially a class of older chemotherapy drugs called anthracyclines — can damage the heart in a small percentage of patients who take them. Although anthracycline drugs are less commonly used now, they are still considered one of the best treatments for breast cancer, Sauri says.

Fortunately, sophisticated cardiac imaging can detect early, subtle signs of heart damage in patients taking these drugs, even before they have any symptoms. The patient’s oncologist can then adjust medication and dosage before the heart is seriously injured, Sauri explains.

Radiation therapy also can damage the heart, though this damage may not occur until decades later. A young adult may have had radiation therapy for Hodgkin’s disease at age 20 but not experience arterial blockages or valve problems related to radiation until age 50, Sauri says.

Fortunately, he notes, once radiation-related heart damage begins to develop, it can be detected via cardiac imaging. If damage is detected shortly after it begins, treatment can be successful.

Sleep apnea

Sleep apnea is a common disorder in which your breathing stops or gets very shallow while you sleep. Breathing pauses can occur more than 30 times per hour. When your breathing stops, your blood pressure goes up and blood oxygen levels drop, putting a strain on your heart.

Those who regularly experience obstructive sleep apnea have an increased risk for cardiovascular disease, concludes a Sleep Heart Health study sponsored by the National Heart, Blood and Lung Institute.

“Sleep apnea has very important ramifications on blood pressure, heart failure, stroke and other types of cardiovascular disease,” says Adhir Shroff, MD, an interventional cardiologist at the University of Illinois College of Medicine in Chicago. “What is fortunate is that there are very good ways to diagnose sleep apnea and multiple types of effective treatments, many of which are relatively non-invasive. With treatment, patients can experience a dramatic improvement in their quality of life as well.”

If you snore, or if you constantly feel tired after a night’s sleep, check with your physician to see if you have sleep apnea. If you do, Shroff adds, it can be treated with a continuous positive air pressure (CPAP) device or devices similar to mouth guards.


Although diet and lifestyle play a key role in heart health, some cardiac conditions are genetic. For example, about 30 percent of cases of dilated cardiomyopathy — when the heart muscle enlarges and doesn’t pump efficiently — are genetically based, Chapman says.

Individuals can inherit a tendency toward high LDL cholesterol as well, so it’s important to get tested if you have a family history, says Ann Davis, MD, a cardiologist with Advocate Heart Institute at Edwards-Elmhurst Health.

Inherited high lipoprotein(a) is also a risk factor for early and aggressive heart disease, Davis says. A blood test can screen people for lipoprotein(a), which carries cholesterol through the blood.

Periodontal disease

Numerous studies have shown an association between gum disease and cardiovascular disease, but is periodontitis a cause of heart disease?

It’s not understood whether gum disease is a sign of systemic inflammation that already exists in the body, Shroff says, or whether bacteria in the gums is getting into the bloodstream and affecting the heart.

Chronic inflammation in the arteries is thought to be the cause of coronary artery disease, Shroff says, “and we wonder if having chronic inflammation in your gums is the same kind of process.”

Although the cause-and-effect link is not clear, there’s clearly an association, Sauri notes, so patients should maintain good oral health and schedule regular dentist appointments.

Herbal teas and supplements

When it comes to your heart health, “natural” doesn’t always mean healthy or safe.

Some herbal teas or supplements contain ingredients that can trigger a rapid or irregular heartbeat, says Shroff, whose patients have experienced such symptoms after taking supplements.

Those are the risks that we pay the most attention to and the ones we try to modify as cardiologists.”

It’s important to know what’s in your supplements, he notes.

Although the Food and Drug Administration requires that supplement manufacturers ensure their products are safe, they are not required to submit safety data before marketing them.

To learn about the uses and potential side effects of herbs and botanicals, check the Herbs at a Glance section on the website of the National Center for Complementary and Integrative Health and be sure to inform your physician about any supplements you’re taking.

Grief and stress

A broken heart is more than a figure of speech. Broken heart syndrome, also known as takotsubo cardiomyopathy, occurs in response to a traumatic emotional event such as a job loss or the unexpected death of a loved one. A part of your heart can temporarily enlarge and fail to pump efficiently, leading to severe, short-term heart muscle failure.

“You can have a cardiac event [due to a traumatic stress] even with perfectly normal arteries,” Davis says.

In addition to acute stressors like the death of a spouse, chronic stress caused by everyday issues like a challenging commute or a fast-paced job is also implicated in cardiovascular disease. A recent Lancet study found that increased activity in a part of the brain involved in the stress response was associated with a greater risk of heart attack or stroke.

As challenging as it can be to avoid stress, some research studies have found that simple practices such as mindfulness-based meditation can help lower blood pressure.

Even simply giving yourself permission to do less and easing the demands you place on yourself can help, Davis says. “I always tell patients, ‘Don’t let perfection be the enemy of great.’”

Air pollution

Where you live might affect your heart health. A 10-year study funded by the Environmental Protection Agency (EPA) found that individuals who live in areas with heavily polluted air develop atherosclerosis (plaque in the arteries) at a faster rate than those who live in communities with cleaner air.

“Spikes in air level quality are associated with spikes in heart attacks, strokes and arrhythmias,” Shroff says.

If you’re concerned about pollution, you can check daily air quality by city at the EPA’s website.

Individuals with heart and lung disease who live in more polluted areas should be aware of dramatic decreases in air quality, but staying indoors continuously is not a great strategy, Shroff says. “Overall, people should continue to be active. There are many positive health effects of being outside.”


Complacency about your heart health can also be a risk factor, Davis says. People often erroneously assume that because they’re young and exercise regularly they’re not at risk for a heart attack or stroke. But you can be youthful and active and still have high LDL cholesterol or high blood pressure, Davis explains.

“Look at the runner Jim Fixx. He never checked for cholesterol, which was elevated, and his family history was significant. He died of a heart attack at 53. You can do all the right things, but you also have to be diligent with your numbers,” Davis says.

Screening for high cholesterol should start early. The American Academy of Pediatrics recommends that children get their cholesterol level checked at age 9 to 11 and again at age 17 to 21.

The U.S. Preventive Services Task Force (USPSTF) recommends that men start getting cholesterol screenings at age 35 or at age 20 if they have risk factors for heart disease. Women age 20 and older with risk factors should have their cholesterol level checked, but the USPSTF doesn’t make any recommendations for screenings for women without cardiac risk factors.

If there’s any indication that a person might be at risk of cardiovascular disease, he or she should be tested, Davis says. “Evaluation is also based on taking a good history and physical exam. If there are risk factors and high suspicion, I would test at that time.”

Be aware, but don’t worry too much

If you’re concerned that you might have a hidden risk factor for cardiovascular disease, your best approach is to have a conversation with your doctor and discuss your lifestyle, family history and medical conditions.

Although it’s good to be aware of hidden risks, physicians stress that you should focus on the big lifestyle factors you can control. In other words, don’t smoke, eat a healthy diet and exercise — ideally at least 150 minutes a week of moderate exercise (think: 30 minutes a day, five days a week).

“Those are the ones that we pay the most attention to and the ones we try to modify as cardiologists,” Chapman says.

“Focus on the big stuff,” Shroff adds. “Often people spend a great deal of time, energy and money on therapies that have minimal or unproven impact on their health. At the same time, they avoid addressing proven but difficult-to-treat issues such as obesity and smoking.”

Originally Published in the Fall 2017/Winter 2018 issue